Background - SCHIP Improvement in Asthma Care After Enrollment in SCHIP
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Background - SCHIP State Children’s Health Insurance Program Improvement in Asthma Care After Enrollment in SCHIP SCHIP in New York State (2002) 1Dept. 4School Low-income children not eligible for Medicaid Peter G. Szilagyi MD, MPH1,2 Andrew W. Dick PhD2 Jonathan D. Klein MD, MPH1,2 Laura P Shone, MSW, DrPH1 Alina Bajorska MS2 Jack Zwanziger PhD4 Lorrie Yoos, PhD, PNP1,3 of Pediatrics 2Dept. Of Community & Preventive Medicine 3School of Nursing $40 billion, block grants to states (10 years) Acts like a separate program (not Medicaid) Administered through MCOs Enrollment = 600,000 (18% of US) Important to measure how well SCHIP works University of Rochester For children in general and those with chronic conditions of Public Health, Univ. of Chicago Study Objectives Children with Asthma Most common chronic physical child condition Describe characteristics of SCHIP enrollees with asthma 5-10% of children More prevalent and problematic among the poor Prevalence in SCHIP Severity of asthma High utilization and costs (visits, medications) NHLBI guidelines for care exist Preventive visits and meds Prior studies: Problems with access if no coverage Measure effect of SCHIP on children with asthma Utilization of services Quality of care Asthma outcomes Subjects: Study Design Main Study- All Children Pre-Post telephone interviews of parents of SCHIP enrollees T1 Interview Soon after enrollment Measurement Period Year before SCHIP T2 12 months later 1st year during SCHIP O Stratified sample of children by: – – – O – To test for secular trends (few trends found) O NYC, NYC environs, upstate urban, rural 0-5 yr, 6-11 yr, 12-18 yr White NH, Black NH, Hispanic 2,644 first-time SCHIP enrollees – Comparison group who enrolled 1 year later Region: Age: Race/ethnicity: Enrolled between Nov 2000 and March 2001 2,290 (87%) completed interviews 1 year later (2001-2002) 400 Comparison group subjects – Random sample Asthma Screener: Prevalence Asthma Screener Methods* 1. Time Period # Children Asthma during: T1 334 (13%) Year before SCHIP T2 364 (14%) Year during SCHIP Wheezing or whistling in chest T1 and T2 213 (8% of T1) Both years O Chest sounding wheezy during or after exercise T1 or T2 472 Either year O Waking from sleep because of cough or wheeze O Wheezing severe enough to limit speech During past year, did MD say child had asthma or 2. Did child have any of the following apart from a cold? O *Questions adapted from NHLBI guidelines – Child had asthma if YES to either #1 or #2 Asthma Screener: Prevalence Asthma Screener: Prevalence Time Period # Children Asthma during: Time Period # Children Asthma during: T1 334 (13%) Year before SCHIP T1 334 (13%) Year before SCHIP T2 364 (14%) Year during SCHIP T2 364 (14%) Year during SCHIP T1 and T2 213 (8% of T1) Both years T1 and T2 213 (8% of T1) Both years T1 or T2 472 Either year T1 or T2 472 Either year Children “grow out” and “grow into” asthma between T1 & T2 Children “grow out” and “grow into” asthma between T1 & T2 Limitations exist in any choice of sample to study Limitations exist in any choice of sample to study Analyses performed multiple waysÆ same results Analyses performed multiple waysÆ same results Questions to Identify Asthma Severity* Questions to Identify Asthma Severity – at T1 - Frequency of asthma symptoms - Frequency of asthma symptoms - Limitations of activities - Limitations of activities - Nighttime awakening due to asthma - Nighttime awakening due to asthma 334 “Mild” *Questions adapted from NHLBI guidelines “Moderate to severe” “Mild ” 202 (60%) “Moderate to Severe” 132 (40%) Results: Demographics of Children with Asthma (N=472) Measures and Analyses Measures Access: Use of care: Quality measures: Asthma-specific: Usual Source of Care (USC), Unmet needs Region: 64% New York city, 18% around NYC Preventive, acute, specialty Age: balanced across ages from 0-17 years % of visits to USC, parent ratings of quality Gender: half male Race and ethnicity: 23% white, 40% black, 34% Hispanic Income: 80% below 160% of FPL Parent Employment: 83% had > 1 parent working Prior Insurance: 71% uninsured >12m before SCHIP Use of care, severity, quality Analyses Bivariate and multivariate Comparing measures: “pre-SCHIP” vs “during SCHIP” Secular trends: Study group vs Comparison group (few found) Results weighted using STATA to account for complex sampling design Access: USC Access: Unmet Health Care Needs Before SCHIP and 1 Year After Enrollment Accessibility Measures (Children with Asthma) Had Usual Source of Care * 100 99 95 90 % Travel > ½ hour to MD Before After 80 29% to 6% ( p<.001) % All kids Difficulty getting appt. 12% to 4% ( p<.01) 70 60 Before SCHIP and 1 Year After Enrollment Wait > 15 minutes at visit No improvement 50 45 40 35 30 25 20 15 10 5 0 * Before After * Any * p<.001 Acute * * Specialty ED Meds *p<.05 Quality: Proportion of Visits to USC Utilization: Percent with Visit/Med Before SCHIP and 1 Year After Enrollment % Preven. * 100 90 80 70 60 50 40 30 20 10 0 * Before After ED Specialty Acute Preventive Meds 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% All Most Some None Before *p<.05 After * p<.001 Quality: Parent Rating of Quality of Care Quality: CAHPS Ratings of Providers 1-10, 10 is highest 10 9 8 7 6 5 4 3 2 1 8.8 7.8 * % Before After Yes 100 90 80 70 60 50 40 30 20 10 0 Overall Rating * 93 84 88 * 75 88 92 89 * 67 Before After Listens Explains Respects Time * p<.001 *p<.05 Problems Getting Care or Meds If Asthma Attack General Health Status 40 35 32 30 % 25 * 20 15 13 13 17 12 Before 12 After 10 % Yes 5 0 Fair/Poor Health Much Worry Less Healthy Than Others 20 18 16 14 12 10 8 6 4 2 0 16 Before 9 After 4 To USC 3 * 2 2 To ED Medications *p<.05 p<.05 Problems Getting Care or Meds If Asthma Attack Reasons for Problems Quality Measures-- ASTHMA Before SCHIP and 1 Year After Enrollment -Cost (60%) Percent of Children with Moderate/Severe Asthma Who Had: -Convenience (10%) % Yes 20 18 16 14 12 10 8 6 4 2 0 16 Before 9 After 4 To USC 3 2 To ED * 2 % 100 90 80 70 60 50 40 30 20 10 0 69 58 24 8 2 Asthma Tune-up Visit Medications p<.05 Before After 38 Preventive Med Action Plan p = NS Change in Asthma or Quality Since Last Year (asked at T2) Reasons for Improvement in Asthma (Among the 75% Who Improved) For ALL children with asthma Much Worse 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Same Quality of Asthma Care 26% 9% Insurance now 1% 18% Just less symptoms 7% 8% Much Better Environment 7% 3% Multivariate Results Adjustments for Demographics did not affect findings Medicines The “SCHIP effect” remained significant for most measures Improvement in “unmet needs” only among Mild Asthma For most other measures, similar pattern if Mild or Severe Adjustments for Demographics did not affect findings The “SCHIP effect” remained significant for most measures Improvement in “unmet needs” only among Mild Asthma For most other measures, similar pattern if Mild or Severe “SCHIP Effect” ------Severe Asthma-----------Mild Asthma------ Unmet Needs Most Visits to USC Unadjusted OR P .2 .006 Adjusted OR P .2 .007 Unadjusted OR P .6 .6 11 <.001 15 <.001 12 <.001 Adjusted OR P .7 .6 12 <.001 “SCHIP Effect” ------Severe Asthma-----------Mild Asthma------ Unmet Needs Most Visits to USC Limitations and Strengths Limitations: O Internal Validity O O O O O Strengths: O Self-report (especially for quality measures) No perfect definition of asthma Possible regression to the mean One state SCHIP (and not Medicaid) First study of SCHIP & asthma, Large N, High follow-up rate Unadjusted OR P .2 .006 Adjusted OR P .2 .007 Unadjusted OR P .6 .6 11 <.001 15 <.001 12 <.001 Adjusted OR P .7 .6 12 <.001 Conclusions Many children with asthma enrolled in SCHIP For children with asthma, during SCHIP: O O O External Validity: O 58% Better Multivariate Results Better Quality of Asthma Care Now has care Worse Asthma Decrease In Severity 39% O O O Improved access to care and reduced unmet needs Change in pattern of care– more care at the USC Improved quality- general (Overall rating, CAHPS, continuity) Improved quality-asthma (Getting asthma care/meds, severity, rating) Reduced parent worry Reasons for improvements- now getting care or meds O Still suboptimal quality on several measures in spite of SCHIP O No improvement in general health status after SCHIP O Tune-up visits and preventive meds for severe asthma Implications for Clinicians Many children with asthma enrolling in SCHIP Their baseline quality of care is poor even though most had a USC Better use of medical home is associated with higher quality during SCHIP Need to do more to improve quality measures Asthma tune-up visits, preventive meds for severe asthma Implications for Policy Makers SCHIP reduces barriers to asthma care and improves access and quality of asthma care Coverage of asthma medications is important SCHIP changed pattern of utilization Implications for Health Plans Many children with asthma enrolling in plans Quality of asthma can improve with coverage but will not reach standards Encourage clinicians to improve quality of care for children with asthma Funders O More use of USC, not more high-cost services (specialty, ED) SCHIP may cause higher initial costs for asthma SCHIP can have spill-over benefits: less parent worry/stress SCHIP (?insurance) more likely to affect a conditionspecific measure than a global health status measure Agency for Healthcare Research and Quality (AHRQ) The David and Lucile Packard Foundation Health Resources and Services Administration (HRSA)
